Functioning transferred free muscle innervated by part of the vascularized ulnar nerve connecting the contralateral cervical seventh root to themedian nerve: case report

<p>Abstract</p> <p>Background</p> <p>The limited nerve sources available for the reconstruction and restoration of upper extremity function is the biggest obstacle in the treatment of brachial plexus injury (BPI). We used part of a transplanted vascularized ulnar nerve as a motor source of a free muscle graft.</p> <p>Case presentation</p> <p>A 21-year-old man with a left total brachial plexus injury had received surgical intercostal nerve transfer to the musculocutaneous nerve and a spinal accessory nerve transfer to the suprascapular nerve in another hospital previously. He received transplantation of a free vascularized gracilis muscle, innervated by a part of the transplanted vascularized ulnar nerve connecting the contralateral healthy cervical seventh nerve root (CC7) to the median nerve, and recovered wrist motion and sensation in the palm. At the final examination, the affected wrist could be flexed dorsally by the transplanted muscle, and touch sensation had recovered up to the base of each finger. When his left index and middle fingers were touched or scrubbed, he felt just a mild tingling pain in his right middle fingertip.</p> <p>Conclusion</p> <p>Part of the transplanted vascularized ulnar nerve connected to the contralateral healthy cervical seventh nerve root can be used successfully as a motor source and may be available in the treatment of patients with BPI with scanty motor sources.</p

Soft Tissue Myoepithelioma of the Shoulder

Soft tissue myoepitheliomas are often misdiagnosed due to their rarity. Herein, we describe a case of soft tissue myoepithelioma of the shoulder. A 72-year-old woman had a suspected sarcoma on her shoulder and under-went open biopsy. She was referred to our hospital, where the tumor was widely resected and the diagnosis of myoepithelioma was histologically confirmed. No recurrence has been observed in the 3 years since the sur-gery. Careful and prompt planning is necessary for the effective treatment of myoepithelioma

Comparison between partial ulnar and intercostal nerve transfers for reconstructing elbow flexion in patients with upper brachial plexus injuries

<p>Abstract</p> <p>Background</p> <p>There have been several reports that partial ulnar transfer (PUNT) is preferable for reconstructing elbow flexion in patients with upper brachial plexus injuries (BPIs) compared with intercostal nerve transfer (ICNT). The purpose of this study was to compare the recovery of elbow flexion between patients subjected to PUNT and patients subjected to ICNT.</p> <p>Methods</p> <p>Sixteen patients (13 men and three women) with BPIs for whom PUNT (eight patients) or ICNT (eight patients) had been performed to restore elbow flexion function were studied. The time required in obtaining M1, M3 (Medical Research Council scale grades recovery) for elbow flexion and a full range of elbow joint movement against gravity with the wrist and fingers extended maximally and the outcomes of a manual muscle test (MMT) for elbow flexion were examined in both groups.</p> <p>Results</p> <p>There were no significant differences between the PUNT and ICNT groups in terms of the age of patients at the time of surgery or the interval between injury and surgery. There were significantly more injured nerve roots in the ICNT group (mean 3.6) than in the PUNT group (mean 2.1) (<it>P </it>= 0.0006). The times required to obtain grades M1 and M3 in elbow flexion were significantly shorter in the PUNT group than in the ICNT group (<it>P </it>= 0.04 for M1 and <it>P </it>= 0.002 for M3). However, there was no significant difference between the two groups in the time required to obtain full flexion of the elbow joint with maximally extended fingers and wrist or in the final MMT scores for elbow flexion.</p> <p>Conclusions</p> <p>PUNT is technically easy, not associated with significant complications, and provides rapid recovery of the elbow flexion. However, separation of elbow flexion from finger and wrist motions needed more time in the PUNT group than in the ICNT group. Although the final mean MMT score for elbow flexion in the PUNT group was greater than in the ICNT group, no statistically significant difference was found between the two groups.</p

Storage and allogeneic transplantation of peripheral nerve using a green tea polyphenol solution in a canine model

<p>Abstract</p> <p>Background</p> <p>In our previous study, allogeneic-transplanted peripheral nerve segments preserved for one month in a polyphenol solution at 4°C could regenerate nerves in rodents demonstrated the same extent of nerve regeneration as isogeneic fresh nerve grafts. The present study investigated whether the same results could be obtained in a canine model.</p> <p>Methods</p> <p>A sciatic nerve was harvested from a male beagle dog, divided into fascicules of < 1.5 mm diameter, and stored in a polyphenol solution (1 mg/ml) for one month at 4°C. The nerve fascicles were transplanted into 10 female beagle dogs to bridge 3-cm right ulnar nerve gaps. In the left ulnar nerve in each dog, a 3-cm nerve segment was harvested, turned in the opposite direction, and sutured in situ. Starting one day before transplantation, the immunosuppressant FK506 was administered subcutaneously at doses of 0.1 mg/kg daily in four dogs (PA0.1 group), 0.05 mg/kg daily in four dogs (PA0.05 group), or 0.05 mg/kg every other day in two dogs (PA0.025 group). Twelve weeks after surgery, electrophysiological and morphological studies were performed to assess the regeneration of the right and left ulnar nerves. The data for the right ulnar nerve were expressed as percentages relative to the left ulnar nerve. Polymerase chain reaction (PCR) was used to identify the sex-determining region of the Y-chromosome (<it>Sry</it>) and β-actin to investigate whether cells of donor origin remained in the allogeneic nerve segments. FK506 concentration was measured in blood samples taken before the animals were killed.</p> <p>Results</p> <p>The total myelinated axon numbers and amplitudes of the muscle action potentials correlated significantly with the blood FK506 concentration. Few axons were observed in the allogeneic-transplanted nerve segments in the PA0.025 group. PCR showed clear <it>Sry</it>-specific bands in specimens from the PA0.1 and PA0.05 groups but not from the PA0.025 group.</p> <p>Conclusions</p> <p>Successful nerve regeneration was observed in the polyphenol-treated nerve allografts when transplanted in association with a therapeutic dose of FK506. The data indicate that polyphenols can protect nerve tissue from ischemic damage for one month; however, the effects of immune suppression seem insufficient to permit allogeneic transplantation of peripheral nerves in a canine model.</p

Effect of a Rehabilitation Program After Mesenchymal Stromal Cell Transplantation for Advanced Osteonecrosis of the Femoral Head: A 10-Year Follow-Up Study

Objective: To assess the status of 10 patients with advanced osteonecrosis of the femoral head who underwent mesenchymal stromal cell transplants and a 12-week rehabilitation program 10 years earlier. Design: Retrospective study. Setting: University clinical research laboratory. Participants: Patients (N=10) who had undergone mesenchymal stromal cell transplantation and rehabilitation for a single hip osteonecrosis of the femoral head 10 years prior to the current study were recruited by telephone. The average age was 31.7 years and all participants were men; radiographic stages were 3A in 6 patients and 3B in 4 patients before treatment. Intervention: A 12-week rehabilitation program with follow-up once every 1 to 2 years was performed after mesenchymal stromal cell transplantation. Main Outcome Measures: Radiographic analysis, clinical score, timed Up and Go test, hip function (range of motion, muscle strength), and Short Form-36 scores were assessed before treatment and 1 and 10 years after treatment. Results: Upon imaging, 5 hips were found to be stable (stable group) and 5 had progressed (progressed group); 2 of the latter group required a total hip arthroplasty. The pretreatment radiographic stage of the progressed group was more advanced than that of the stable group. Body mass index was higher in the progressed group than in the stable group. Hip function and clinical score at 1 and 10 years after treatment improved in the hips of 8 patients without total hip arthroplasty. There were no severe adverse events during the rehabilitation. Conclusions: The 12-week rehabilitation program and annual follow-up after mesenchymal stromal cell transplantation for osteonecrosis of the femoral head was associated with pain reduction, maintaining hip muscle strength, widening range of motion, and improving quality of life. The level and timing of weight-bearing and social activity should be planned according to the individual's lifestyle and body composition

The neuroprotective effect of erythropoietin on spinal motor neurons after nerve root avulsion injury in rats.

The rapid death of many spinal motor neurons after nerve root avulsion injury results in limited functional recovery following replantation surgery of avulsed nerves into the spinal cord. Therefore, we investigated the neuroprotective effect of erythropoietin (EPO) on motor neurons after nerve root avulsion injury using a rat model

<原著>神経外膜を利用した神経再建方法 : 神経断端の大きさが異なる場合の神経修復

We report a new method of nerve Reconstruction, wrap-around neurorrhaphy, in which the funicular suture site is wrapped with the epineurium of the larger stump. The specific applications of this procedure in brachial plexus reconstruction are described and the clinical results presented. The method was applied in intercostal nerve transfer to the musculocutaneous nerve in 21 patients and in 12 patients with axillary nerve injury who underwent reconstruction with autografts using wrap-around neurorrhaphy. Rigid fixation of the neurorrhaphy site could be obtained using this method, and the clinical results were satisfactory.神経再建にあたって, その縫合方法には神経外膜縫合, 神経周膜縫合, 神経外膜・周膜縫合などがある. 実際には神経の種類・部位・状態などによって, その縫合方法を変えているのが現状である. 神経外膜を温存・利用して, 神経再建した場所を包みこむ神経再建の方法(wrap-around neurorrhaphy)を記述し, その適用と臨床結果を発表したこの神経再建方法は, 神経周膜縫合部位の緊張を防止し, 神経束の整然とした包み込み(packing), そして強固な神経連結を目的とする. 神経断端の大きさが著しく異なる時の神経縫合, あるし、は関節可動威か大きくて縫合部位に緊張が推定される時の神経縫合には, この方法(大きい方の神経外膜で縫合部位を包む方法)の良い適用がある. この方法で神経を再建し, 術後2年以上経過している臨床症例の結果をまとめた. 症例は, 肋間神経移行術(互いの神経断端の大きさが著しく異なる例として)の21症例と, 版窟神経再建術(関節可動域が大きい場所での神経再建例として)の12症例である. 神経外膜を利用して, 神経縫合した場所を包みこむ神経再建方法は, このような症例にきわめて良好な適用かある

Treatment of angiomatoid fibrous histiocytoma after unplanned excision: a case report

Abstract Background Angiomatoid fibrous histiocytoma (AFH) is a relatively uncommon soft tissue tumor of intermediate biologic potential. It occurs in subcutaneous regions of the extremities or the trunk, usually presenting in children or young adults. This is the first reported case of subcutaneous AFH that developed in the iliac region and was treated with an unplanned resection. Case presentation An 11-year-old girl noticed a small subcutaneous nodule in the iliac region. As the nodule was asymptomatic, it was observed naturally for a year, after which her parents consulted her doctor due to gradual growth of the nodule. The tumor was resected marginally without biopsy by a non-specialized surgeon. Based on the histology of the resected specimen, the tumor was suspected to be a sarcoma. The patient was referred to our hospital where we reinvestigated the histology of the tumor using immunohistochemistry. After confirming diagnosis of the tumor as an AFH, we undertook additional extensive resection in the iliac region where the tumor had developed. There was no evidence of tumor residue in the resected specimen. It has been 3 years since the operation, and there has been no evidence of recurrence. Conclusion We treated a case of AFH after unplanned resection. If subcutaneous tumors in the iliac region are detected, a diagnosis of AFH should be considered and a simple resection avoided

Bio-permeable nerve conduits containing isogenic acellular muscle basal lamellae and bone marrow mesenchymal stem cells

シリコンチューブ内に腓腹動静脈茎、同種無細胞性神経基底膜、骨髄幹細胞を移植した神経誘導管を作成し、ラット坐骨神経の20mm欠損を架橋した。結果は新鮮自家神経移植での神経再生とほぼ同等の神経再生を獲得できた。同種神経の使用には、移植免疫、感染、倫理問題など解決しなければならない多くの問題がある。我々は、無尽蔵に採取でき、移植に伴う拒絶反応がなく、また移植倫理で問題のない自家筋肉基底膜に着目した。本研究では、同種無細胞性神経基底膜の代わりに自家無細胞性筋肉基底膜をシリコンチューブ内に挿入し、神経再生を観察した。神経再生にはシュワン細胞が移動できる構造的空間が必要である。We have created an artificial nerve conduit model made of a silicone tube containing a sural vascular pedicle and decellularized allogenic nerve basal lamellae implanted by bone marrow derived mesenchymal stem cells. The nerve regeneration through the tube with a 20mm-interstump gap in a rat sciatic nerve was almost equal to that through a 20mm-long fresh nerve isograft. However, the use of allogenic nerves in the clinical setting is associated with several big problems that should be solved, including immunological responses, infectious disease transmission and ethical problems. The aim of this study was to investigate whether decellularized isogenic nerve basal lamellae (DIML) could be a substitute of decellularized allogenic nerve basal lamellae (DANL). Nerve regeneration occurred in the DANL and around the DIML. Scaffolds promoting nerve regeneration need the space that accommodates Schwann cell migration.研究分野：手外科、末梢神経外科

An exploratory clinical trial for idiopathic osteonecrosis of femoral head by cultured autologous multipotent mesenchymal stromal cells augmented with vascularized bone grafts.

Idiopathic osteonecrosis of femoral head (ION) is a painful disorder that progresses to collapse of the femoral head and destruction of the hip joint. Although its precise pathology remains unknown, the loss of blood supply causing the loss of living bone-forming cells is a hallmark of the pathophysiology of osteonecrosis. Transplantation of multipotent mesenchymal stromal cells (MSCs) is a promising tool for regenerating the musculoskeletal system. The aim of the present study was to assess the safety and efficacy of transplantation of cultured autologous bone marrow-derived MSCs mixed with β-tricalcium phosphate (β-TCP) in combination with vascularized bone grafts for the treatment of advanced stage ION in a clinical trial. Ten patients with stage 3 ION were enrolled in this study. Autologous bone marrow-derived MSCs were cultured with autologous serum, and cells (0.5-1.0×10(8)) were transplanted after mixing with β-TCP granules in combination with vascularized iliac bone grafts. Patients were assessed 24 months after treatment. The primary and secondary endpoints were progression of the radiological stage and changes in bone volume at the femoral head, and clinical score, respectively. Nine of ten patients completed the protocol, seven of whom remained at stage 3, and the remaining two cases progressed to stage 4. The average bone volume increased from 56.5±8.5 cm(3) to 57.7±10.6 cm(3). The average clinical score according to the Japan Orthopaedic Association improved from 65.6±25.5 points to 87.9±19.0 points. One severe adverse event was observed, which was not related to the clinical trial. Although the efficacy of cell transplantation was still to be determined, all procedures were successfully performed and some young patients with extensive necrotic lesions with pain demonstrated good bone regeneration with amelioration of symptoms. Further improvements in our method using MSCs and the proper selection of patients will open a new approach for the treatment of this refractory disease